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For Elizabeth:
908-469-2888
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For Perth Amboy:
862-300-3666
Elizabeth
908-469-2888
908-469-2882
info@aqmdi.com
Edison
732-662-1831
732-662-1833
Perth Amboy
862-300-3666
862-300-3667
About Us
Our Services
Open MRI
Closed1.5T Wide Bore MRI
CT Scan
Digital X-RAY
Ultrasound
Digital Mammography
DEXA
Affordable Imaging
Womens Imaging
Patient Resources
Patient Forms
Exam Preparations
Affordable Imaging
Tutorials
FAQ
Our Radiologists
Radiologists Info.
Locations
Elizabeth
Edison
Perth Amboy
Blog
Contact Us
Menu
About Us
Our Services
Open MRI
Closed1.5T Wide Bore MRI
CT Scan
Digital X-RAY
Ultrasound
Digital Mammography
DEXA
Affordable Imaging
Womens Imaging
Patient Resources
Patient Forms
Exam Preparations
Affordable Imaging
Tutorials
FAQ
Our Radiologists
Radiologists Info.
Locations
Elizabeth
Edison
Perth Amboy
Blog
Contact Us
Bone Density Questionnaire
Please enable JavaScript in your browser to complete this form.
Full Name
*
Email
*
Phone
Date
*
Age
*
Date of birth
*
Weight:
*
Height
*
Ethnic Background please circle:
*
Caucasian
African American
Hispanic
Asian
Indian
Other:
*
Have you ever had a bone density before?
*
Yess
No
Date of Last study:
*
Where?:
*
Date of last menstrual period:
*
Have you reached menopause?
*
Yes
No
if yes, At what age:
Have you ever had a total or partial Hysterectomy?
*
Yes
No
At what age:
*
Why?
*
Were your ovaries removed?
*
Yes
No
Any family history of osteoporosis?
*
Yes
No
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you exercise?
*
Yes
No
Are you right handed?
*
Yes
No
Have you had a fracture or had surgery on:
Spine:
*
Yes
No
if yes,
*
Yes
No
Hip:
*
Yes
No
if yes,
*
Yes
No
Forearm/wrist:
*
Yes
No
if yes,
*
Yes
No
Have you had other fractures?
*
Yes
No
if yes, where
Have you lost 2 inches in HEIGHT in recent years?
*
Yes
No
Have you had an xray/nuclear scans in the last 2 weeks?
*
Yes
No
if yes, Specify:
Do you take estrogen, progesterone or any hormonal medications?
*
Yes
No
Do you take any of the following medications?
*
Yes
No
Estrogen
Fosamax
Evista
Miacalcin
Calcium Prednisone/Steroid
Thyroid Medication
Seizure Medication
for how Long:
Do you have any of the following:
Absence of menstrual before menopause
Diabetes Mellitus
Any thyroid condition?
Hypertension
Testosterone deficiency
Anxiety/Depression
Cushing’s syndrome or Gaucher’s disease
Intestinal disease, Malabsorption
Liver or Kidney disease?
If yes, Hyper or Hype?
Are you on Dialysis?
*
Yes
No
List medications
*
Patients signature
*
Date
*
Send
